Why some kids keep getting infected tonsils — and how to fix it

B cells (blue) team up with T cells (green) in areas known as germinal centers (red) within tonsils. This helps B cells in the germinal center mature into antibody-producing cells.

B cells (blue) team up with T cells (green) in areas known as germinal centers (red) within tonsils. This helps B cells in the germinal center mature into antibody-producing cells. (Meghan Rossi, La Jolla Institute for Immunology)

The scientists examined tonsils removed at Rady Children’s Hospital San Diego. Some tonsils had previously been repeatedly infected with Group A Strep bacteria, a major reason for tonsillectomies. Other tonsils were removed because they obstructed breathing during sleep, but had not been repeatedly infected.

Tonsils that had been repeatedly infected showed evidence of reduced immune capacity, they found. And some infections were associated with a genetic difference.

If children vulnerable to recurrent infections can be identified beforehand, they could have their tonsils out sooner rather than later, the study said. Eventually, it may be possible to develop vaccines against Group A Strep, boosting tonsil immune function in these infection-prone children.

“It's conceivable in the future that you could do a simple genetic test on kids and have information about their likelihood of being susceptible to recurrent tonsillitis,” Crotty said.

More research is needed to determine if these findings hold up, said the scientists. But if valid, they said it’s a significant advance in childhood health care. A pediatric infectious disease specialist not involved in the study concurred.

Group A Strep bacteria cause an estimated 600 million cases of strep throat annually. This causes fever, swelling of the tonsils and enlarged lymph nodes. This not only produces misery for the children, but also lost school time, and in some cases, lost work time for concerned parents.

And there’s the possibility of later complications, especially in countries without widespread access to modern health care.

“Recurrent strep infections can lead to rheumatic heart disease,” Crotty said. “That's not a problem in the U.S. because the strep infections get treated by antibiotics and they don't last that long. But that's the most serious causes of pediatric heart disease in the world, 100,000 cases a year or more.”

Repeatedly infected tonsils had smaller “germinal centers,” places where immune cells interact and prepare to fight infections, said Crotty, who has extensively researched the role of these important immune structures in relation to HIV.

The tonsils also had fewer immune cells called T follicular helper cells, that direct immune response to strep infection. Patient blood samples had lower levels of antibodies against a strep toxin called SpeA.

In addition, researchers found some children had variants in what are called human leukocyte antigen genes. These variants were linked with a greater risk of recurrent strep tonsillitis. These children may be genetically disposed, Crotty said.

Dr. Stanford Shulman, a professor of pediatrics at the Feinberg School of Medicine at Northwestern University, praised the study, while cautioning that the findings require confirmation.

“The immunologic studies that are presented are really quite elegant,” said Shulman, whose research focuses on Group A Strep. “I do think this is an important paper.”

Shulman said further work is needed to insure that the infected tonsil group didn't include children who were actually chronic carriers of strep who were experiencing frequent viral infections, rather than recurrent strep infections. In the non-infection group, the reasons that the tonsils overgrow and obstructed need to be studied

The study said larger numbers of tonsils need to be examined for more definitive findings. Scientists examined 66 tonsils from children with recurrent infections, and 80 from children without recurrent infections.

Removal of the tonsils is the second-most common pediatric procedure, behind ear tube placement. More than 750,000 tonsillectomies are performed annually in the United States. Many of these are performed because of repeated tonsil infections, most of the rest because of sleep apnea caused by overlarge tonsils.

Tonsillectomies should be considered for children who have had seven or more infections a year, according to American Academy of Otolaryngology guidelines.

The procedure used to be performed routinely to treat tonsil infections. Doctors have raised the bar for tonsil removal in part because there is a risk from surgery, said study coauthor Dr. Matthew Brigger, associate professor of clinical surgery at UC San Diego. There’s also a growing awareness that children benefit from the immune functions of tonsils.

“We’re trying to be a little bit more selective about who have their tonsils removed,” said Brigger, also chief of the Division of Otolaryngology at Rady Children’s Hospital San Diego.

Study funders include the Thrasher Research Fund and the National Institutes of Health.

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